- Posted by Canopy KC
- On March 20, 2017
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Common Health Insurance Terms
By definition at merriam-webster.com, Health Insurance is insurance against the loss through illness or insurance providing compensation for medical expenses. Realistically, that definition should be taken at face value because there are multiple common health insurance terms that are the core of what health insurance coverage actually is. Continue reading for definitions of the top ten common health insurance terms that constitute your coverage.
Claim: An itemized statement of healthcare services and costs provided by a provider or facility. Claims are submitted to the insurer by the member or the provider.
Co-Payment: A specified dollar amount that the member must pay out of pocket at the time the service is rendered.
Deductible: A set dollar amount that a member must pay prior to the insurer making any benefit payments. This amount is based on a percentage amount established by the member’s contract.
Dependent: Either a spouse or child that is covered under the primary insured member’s plan.
HMO: Health maintenance organization (HMO) provides comprehensive medical services in a particular geographic location. An HMO is specific to in-network providers.
HSA: Health Savings Account (HSA) is a personal savings account that allows a member to accrue pre-tax dollars to pay for approved medical expenses.
In-network: Health care provider, facility, or pharmacy that is inclusive under a health plan’s network of preferred providers. Generally speaking, a member will pay less for services received from in-network providers secondary to a negotiated rate between provider and health insurance company.
PPO: Preferred provider organization (PPO) provides comprehensive medical services with both in-network and out-of-network providers; however, by using providers in-network you receive greater coverage.
Premium: Monthly dollar amount that is paid individually or by an employer in exchange for health insurance coverage.
Out-of-Network: Health care provider, facility, or pharmacy that is not included under a health plan’s network of preferred providers. A member will pay more for services rendered at or with an out-of-network provider.
Pre-certification: The pre-notification to a member’s plan, in advance, of plans for a patient to undergo a course of treatment or care such as surgical intervention or diagnostic testing. Also known as prior authorization.
Denial of Claim: The refusal of an insurance company to pay for health care services obtained from a health care professional for a covered individual.
Understanding these common health insurance terms is a good start to becoming a smart consumer when it comes to health insurance coverage, but like most things insurance, there is always more. Here at Canopy, you can always count on a free consultation at our local office with a licensed agent, who will always be willing to define a common or not so common health insurance term whenever you need.